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EXPERIENCE & REASON |
b Department of Pediatrics, Ambulatory Care Clinic
c Pediatric Critical Care
d Pediatric Endocrinology
a University of New Mexico College of Medicine, Albuquerque, New Mexico
ABSTRACT
Bloody nipple discharge is a rare finding in infants and is associated most often with benign mammary duct ectasia. The rarity of this symptom in infants and its association with breast carcinoma in adults can lead to unnecessary investigation and treatment. Here we describe a 4-month-old boy with bilateral bloody nipple discharge that resolved spontaneously without treatment by 6 months of age. Furthermore, we propose a strategic method for the evaluation of such infants.
Key Words: blood • breast/pathology • breast/secretion • breast/surgery • breast neoplasms • infant • mammary duct ectasia • mastectomy • nipples/secretion
Infantile bloody nipple discharge, although rare, can be very distressing to the child's parents and health care providers. Although this finding can be associated with breast carcinoma in adults, all of the reported cases in infants have been found to be benign processes.1–10 The diagnostic workup in several of these infants involved invasive procedures, including mastectomy.5,6 Evaluation of bloody nipple discharge in infants on the basis of its associated pathologies in adults can lead to unnecessary and deforming procedures, worry, and cost. Here we present a typical case of bilateral bloody nipple discharge in a 4-month-old boy. After discussing this case, we suggest an approach to evaluation of bloody nipple discharge in infants.
CASE REPORT
A 4-month-old male presented with bilateral bloody nipple discharge without associated breast hypertrophy. The discharge was intermittent for 
2 months, beginning initially as a thin, whitish fluid and then becoming a thicker pinkish/red discharge over time. The parents denied any manipulation or palpation of the breast tissue and did not notice any associated change in the size of the breasts. The past medical history was unremarkable, including a term delivery without complications, no surgical history, and no medications. The child was breastfed. The physical examination revealed a small amount of serosanguinous discharge from both nipples. There was no palpable mass in either breast and no evidence of enlarged breast tissue. The remainder of the physical examination was unremarkable, with normal male genitalia and bilaterally descended testes.
Prolactin and estradiol levels were within the age-appropriate reference range at 17.05 ng/mL and 18 pg/mL, respectively. Culture of the discharge was negative, and no white blood cells were observed on microscopy. Ultrasound was suggested, but the family did not follow through. At the 6-month checkup, the discharge had resolved completely and there was no palpable breast tissue; the parents reported that the discharge ceased by time the child was 5 months old. Breastfeeding was discontinued at 4 months of age.
DISCUSSION
In the past 25 years, there have been 7 published cases of bloody nipple discharge in infants and 3 cases in children <4 years of age. In 1983, Berkowitz and Inkelis3 reported the first 2 cases of bloody nipple discharge in a male and a female infant, both 6 weeks old. Both patients presented with unilateral bloody nipple discharge and ipsilateral breast hypertrophy without evidence of infection. Neither imaging studies nor surgical intervention were performed, and after careful observation, the girl had full resolution of all symptoms by 9 months of age and the boy exhibited a decrease in breast size and only a small amount of bloody discharge at the 1-month follow-up. The bloody discharge was thought to be an unusual response of neonatal breast tissue to maternal hormones, similar in etiology to bloody nipple discharge in pregnant women.
Stringel et al4 reported cases of bloody nipple discharge in a 3-year-old boy and a 5-month-old girl. After 3 months of discharge from the right nipple, an ipsilateral subcutaneous mastectomy was performed on the boy. Histologically, this specimen was consistent with mammary duct ectasia, a benign process revealing dilated ducts with eosinophilic infiltrate, and periductal fibrosis with numerous inflammatory cells. One year later, these symptoms recurred on the left side; a subcutaneous mastectomy was performed again, revealing similar histologic findings. The 5-month-old girl had a small nodule beneath the areola of the affected nipple; she was observed carefully without intervention, and the discharge resolved in 3 months. Miller et al5 reported similar findings in a 4-year-old boy. A bilateral mastectomy was performed in this case, and both specimens revealed histology indicative of mammary duct ectasia.
Olcay and Gokoz6 reported bloody nipple discharge in a 2-year-old boy. After a 3-month history of discharge from the right breast with hypertrophy, a subcutaneous mastectomy was performed and the specimen revealed similar histology as that described by Stringel et al. Weimann7 reported an 8-month-old boy with a 4-month history of bilateral bloody nipple discharge and no associated breast enlargement or evidence of infection. After determining normal levels of prolactin, thyrotropin, and estradiol and a normal head ultrasound, an ultrasound of the breasts revealed dilated mammary ducts on both sides. Six months later the discharge had resolved completely.
The remaining 3 case reports included 2 letters to the editor in response to Berkowitz and Inkelis3 that reported similar cases of spontaneously resolving bloody nipple in infants. Fenster8 reported bloody discharge in an 8-month-old boy that resolved without complication by 15 months of age. In Greece, Sigalas et al9 found a case of bloody nipple discharge in a 7-month-old boy associated with a mildly elevated progesterone level; the discharge resolved in 6 weeks, and progesterone levels returned to normal. In 1992, a case of bloody nipple discharge in a 3-month-old girl was published in the Hebrew language10; the available English-language abstract reported resolution of symptoms by 9 months of age without intervention.
Of the few case reports of bloody nipple discharge in infants, the most common cause is mammary duct ectasia. This process consists of dilated mammary ducts and periductal fibrosis and inflammation, with no clear etiologic explanation. We found very few cases of breast carcinoma in children between the ages of 3 and 18 years since 1917 and no reported cases in children <3.11,12 The chief presenting symptoms were breast lumps and local pain, with only 1 report of bloody nipple discharge in an adolescent.11,13 Pituitary adenomas, specifically prolactinomas, can present as nipple discharge; however, the discharge is milky and usually bilateral. In a 1998 study of the clinical presentation of prolactinomas in children and adolescents, patients were identified between ages 7 and 17 with presenting symptoms of headache, visual defects, and amenorrhea (in females); galactorrhea was present in approximately half of the patients. Bloody nipple discharge was not noted as a presenting symptom in prolactinoma.14 Mastitis generally presents as unilateral breast pain and erythema but can be accompanied by a purulent or multicolored nipple discharge if there is an underlying abscess.15,16 In addition to the unlikely association of bloody nipple discharge with mastitis, the condition is uncommon in infants, and when it does occur, it usually occurs before 6 weeks of age (mastitis neonatorum).17
King et al1 and Jardines2 both published diagnostic approaches to the evaluation of nipple discharge in men and women over the age of 30. Unfortunately, neither of these approaches seem applicable to infants. We propose a diagnostic approach to the evaluation of bloody nipple discharge in infants.
In an infant presenting with apparently bloody nipple discharge, an initial workup should include Gram-stain; cell count and culture of the discharge; serum levels of prolactin, estradiol, and thyrotropin; and an ultrasound of the affected breast(s). If hormone levels are abnormal, especially if there is an elevated serum prolactin level, an endocrine consultation and MRI of the head specifically to evaluate the pituitary gland should be obtained.14 If the culture is positive or if the clinical picture suggests infection, the child should be treated for mastitis.17 If ultrasound of the breast reveals a mass or abnormality other than mammary duct ectasia, a pediatric surgical consultation versus watchful waiting should be considered.1,2
If hormone levels are within the reference range, the culture and Gram-stain are negative, and the ultrasound reveals normal breast tissue or mammary duct ectasia, we suggest expectant follow-up and reassurance to the parents. Given unremarkable findings in all of the preceding investigations, both bilateral and unilateral discharge is likely to be benign in infants despite the higher correlation of unilateral discharge with pathologic changes in adults.1,2 Therefore, we do not suggest a unique follow-up for bilateral versus unilateral discharge in infants in the absence of other findings.
Presence of a palpable mass beneath the affected nipple is not included in the analysis, because the diagnosis of mammary duct ectasia has been made with and without the presence of breast hypertrophy or palpable mass.5,7 Therefore, we did not feel that classification based on this clinical finding was helpful in diagnosis. Instead, we chose further clarification by ultrasound with or without the presence of a clinically palpable mass. Although there is little evidence to dictate the necessity of an ultrasound, it is painless, noninvasive, and without adverse effects. Additional investigations such as ductography and additional cytology have been used in the evaluation of nipple discharge; however, they have not been shown to have a significant diagnostic benefit in adults.1,2 Although duct excision was performed in several of the case-patients, there does not seem to be a clear benefit from the procedure, because all of the excised specimens revealed benign duct ectasia, and excision may cause permanent deformity or dysfunction of the breast tissue.4–6
The type of feeding (breastfeeding versus formula) was ultimately not included in the evaluation of bloody nipple discharge. Although our patient was breastfed until 4 months of age, there is no evidence that breastfeeding is an important variable in the etiology of bloody discharge, because it has been documented equally in breastfed and formula-fed infants, as well as in significantly older children.
Finally, because most reported cases of ductal ectasia resolved in <9 months, if the discharge does not resolve in 6 to 9 months, a pediatric surgical consultation may be considered regardless of other findings.
CONCLUSIONS
Given that the etiology of adult and infantile bloody nipple discharge are dramatically different and that all reported cases in infants have been benign, we suggest a conservative approach to the problem. Our proposed method of evaluation of apparently bloody nipple discharge in infants may lead to fewer invasive procedures and less worry for parents over a condition for which there seems to be an exceptionally low likelihood of serious pathology.
FOOTNOTES
Accepted Oct 13, 2005.
Address correspondence to Victoria M. Kelly, 4328 Altura Mesa Lane NE, Albuquerque, NM 87110. E-mail: vmkelly{at}salud.unm.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
REFERENCES
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